Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, March 14, 2008

Smoke Scream

My parents were smokers; in the case of my dad, it was three or four packs a day for forty years before he just up and quit one day, cold turkey, many years ago (not soon enough to avoid the need for home oxygen at the end of his life. But still...) Mom smoked far less, and quit the same day he did. After my grandfather's heart attack, he quit, too; but usually kept an unlit Tareyton in his mouth -- the kind with the cardboard tube on the end -- to chew on. Until his stroke.

Of course I took it up. Stole packs from my dad's pockets and sneaked with eighth-grade friends down to the swamp behind Reed College, smoked and coughed until we got the hang of it, and proceeded to be cool. I blew great smoke rings, learned the "French Inhale," could light a match in a matchbook with one hand, pop a flame with my fingernail, or on my shoe. I didn't smoke much until college, and then it was only five or ten sticks a day. I kept it up, I'm embarrassed to say, through med school and even -- more's the shame -- while a surgical intern. Somewhere there's a picture of me at the VA Hospital, working on a chart, wearing my whites, cigarette polluting coolly from my hand.

On the day I got married I quit but began again three months later, when I shipped off to Vietnam. Cigarettes were so cheap over there, I really couldn't afford not to. The last cigarette I ever had was when the stewardess (flights back to The World were on Pan Am jets -- "Freedom Birds," we called them) announced we were about to land at Travis AFB. Skrunked it out, and that was that.

I mention all this to confer authority when I say what a terrible thing it is to do. How easy it is to tell smokers when operating, and when caring for them afterwards. Not to mention when first seeing them from across the room, or hearing them. Lady who looks twice her age, facial skin wrinkled like a scrotum in winter, voice sounding like shifting gears without the clutch. Guy with a chest over-expanded by trapped air, honking up crud into a brown and stiff tissue. Holding it with yellow fingers.

Put smokers to sleep, they cough on their breathing tubes; the gooey crap that needs to be sucked out of their lungs to keep their oxygen levels up looks rotten, thick in pus. Brown, or green, or black. Or red, sometimes. The corruption thus vacuumed out streaks the tubing for a foot or two, slime from a dying slug. A smoker bucks like a horse untamed when waking up, straining sutures scarily. Many a time I've leaned on an incision to keep it from coming apart, a desperate sort of single-stroke CPR, waiting for the anesthetist to get them calmed down. When still in training, I had a smoker-patient wake up with such a convulsive cough that it popped every single stitch, pk-pk-pk-pk-pk-pk, like a tommy-gun, which is what led to taking up the leaning maneuver (as well as a change in suturing methods.)

Smoking retards healing. It increases the risk of leaks where we sew bowel, and of wound dehiscence or late herniation. If you want much in the way of cosmetic surgery and you're a smoker, fergit it until you quit. The chance of successful limb-salvage surgery -- bypass grafts around blockages and hooked to small distal vessels -- is greatly reduced in smokers; welcome to Stumptown. (I used to live there.) In hospitals, particularly on surgical floors and in ICUs, evidence of the hazards of smoking is everywhere. Opening a chest and seeing a normal lung, pink as a baby's tongue, fluffy as a feather, is as rare as it is beautiful.

When I worked at that VA hospital, I saw guys holding cigarettes in stubs of former fingers, sucking smoke into a tracheostomy. Rules be damned: people sneak out to stair wells or onto fire escapes to smoke after surgery. And lie about it after, oblivious to their smell. It's rough. The good news is that, in regards to surgery and anesthesia, the effects are lessened to some degree even with a week of abstention. Much longer is much better.

My advocacy does have limits. I thought it cruel and stupid when an attending refused to let a patient, dying of lung cancer, have the pleasure of a smoke. What's done is done. Give a guy a break.

31 comments:

Thanks for this post. I'm one of the lucky ones. I smoked some in high school and college, but I was able to quit smoking only once, in 1977, without a relapse. My husband, however, smoked for probably 40 years and now has advanced COPD and emphysema. He's an otherwise robust 59 year old guy who looks great on the outside but must use oxygen and take a cabinet full of drugs (various inhalers, nebulized albuterol, pills, etc.). He can no longer work, but he stays as active as he can. Although we still travel, we must make arrangements for oxygen and we must always allow for long layovers when we fly because he can't run through an airport for a plane. Much of our life is organized around managing his disease. Nicotine is a terrible addiction, and hard to quit. Whenever I see kids smoking, I wish I could just take them by the hand and show them my husband: this is what will happen to you. Not if, but when.

Dr Sid, like you as a teenager I "stole" one of my mom's cigarettes. Trying to copy the adults. Thank God I choked so badly when I inhaled that first time that I NEVER tried another one. Some of my siblings weren't that lucky.

Another "near miss" almost smoker here, but my mother's unfiltered Pall Malls smelled so bad that I held my breath and ran out of the house on school mornings, as they made me nauseated.

Had the experience of a patient smoking via his trach, while on portable O2 - during his wheelchair transfer from the SICU for vascular probs to a regular surgical bed. The volunteer wheeling him was clueless. Also worked with an onc-ENT surgeon who refused to write DNR orders for any of his patients. So they would be resusciated until they succumbed from all of the mechanical chest damage. Ever try to maintain an airway on a long term chemo/irradiated/surgicaly excised missing jaw and face patient? That's one memroy that I'll never be able to shake. And they were almost always the patients who we rolled outside so they could smoke through whatever airway they had left. Damn nicotine and the corporations who even now, are increasing the nicotine doses in cigs while shortening them. Really something.

My dad too smoked most of his life - until in his early 60's when asbestosis reared it's ugly head (due to years of exposure, starting in his teens repairing steam engines for UP, then later as a mechanical contractor building & repairing boiler plants). His lungs didn't get him in the end though - a brain aneurysm 10 years later did.

My mom was a non-smoker, and I managed to avoid it as well, though my younger brother & sister both took up the habit.

And be nice when you talk about "Stumptown" some of us still live here! We may not be as big or modern as Seattle, but the commutes are a whole lot better - and at least we're going to get to keep our NBA team! :-)

Some doctors refuse to allow their patients a cigarette? How does that actually play out?

If both sides really pushed the issue, the presumable result would be that the patient confronts a choice: either depart the hospital AMA, or light up on the premises and face legal consequences for trespassing/reckless endangerment (depending on what kind of contract they signed on admission, and given the presence of medical o2). But neither of those involve the physician no allowing the patient to smoke, per se.

I'm guessing that what actually happens is both sides DON'T really push the issue. I bet attending doctors tell patients they are not allowed to smoke, and patients, being passive like may patients, believe them. Which (to me) only goes to show how iron clad a nicotine addiction is NOT.

Anyway. What the hell do I know?

My second observation has to do with a conversation with a friend about two weeks ago, in which I suggested that cigarettes are just not on the radar for my generation the way they were for previous generations. (My friend is in his 40's, I am 25.) He countered by suggesting that there is a class issue, in that I am also a well educated white guy in a university town, and not, say, a janitor in a mill-town. He suggested that although smoking may not be on the radar for me, I an not necessarily representative of my entire generation either.

But Dr. Schwab's post cuts against his argument. Because (I am pretty sure) that Dr. Schwab comes from a well educated, intellectual family. Which suggests that the educated middle/upper class of previous generations also enjoyed their tobacco. So, while I may be representative of the social class from which Dr. Schwab hails, that class in my generation has moved away cigarettes.

This is all a long way of me trying to bend Dr. Schwab's post to my own narcissistic ends: Smoking is becoming progressively less cool among the more educated in my generation, and I am living proof that my friend is mistaken.

That covers the college educated. With respect to the less fortunate, well, at 5 bucks a pack and rising, things are looking up for those mill-town janitors as well.

patrick: two aspects. First, nowadays it's generally a hospital policy, ie, patient sign an understanding that smoking is not allowed. It was not always so.

Second, as you may already know. A generation ago, smoking was cool, was promoted as cool, and there were commercials showing "doctors" smoking and recommending a particular cigarette. The "smoking as actually bad for you" concept is relatively new. Used to be that everyone smoked in movies, on TV. I'd say it's mainly the clear connection to disease that's only been promulgated in the last few decades -- along with "banning" it from ads and media -- that's change things so dramatically.

For others, smoking is a DAMN hard thing to give up. Why do some people fall so much harder than others? Are we lacking the fortitude, the inner discipline, the smarts? Are we just weak and maybe lesser people?

I am one of those who fell HARD In the first week I started smoking, I was up to a pack a day by Saturday. Age 13. Three to five packs per day for the next 20 years.

Then the REAL struggles began...trying to quit. Pretending I had quit. Substituting other addictions.

I have surrendered the smokes, only to replace them with nicotine replacement product addiction. Shameful and weak but damn if I can give this up...it has been going on for years. Thank god they have become OTC.

My husband's papa was a surgeon. We keep our loose change in a 1952 ladies hospital auxillary award ashtray that his mama got -- an engraved ashtray being a dandy gift at the time. Useful and beautiful.

My toddler son is on oxygen because he has Interstial Lung Disease. Being around smokers is HORRIBLE for his lungs. I have had soooo many smokers light a cigarette right in front of my son, and it can be clearly seen he is on oxygen.

It's also a fire risk. No open flame is supposed to be by oxygen.

I also often have to go past, I will say inconsiderate people that are smoking right by the doors of the hospital, with my son in his stroller, on oxygen. (and no smoking signs right next to them).

I honestly feel like people smoking on hospital grounds where, it says there is no smoking allowed on the hospital grounds, should be kicked off the property. Period. Sorry but my son should not have to endure more lung damage and possibly um, FIRE because some idiot lights a cigarette or puts his ciagrette with my son in touching distance.

If people want to smoke in there own home, I could care less, but when do it around my son, i find them very selfish and inconsiderate.

this stuff has just brushed up my old memories.i was also a chain smoker.i thought it to be coll and a style symbol,untill one day.i woke up in the morning and looked at my hands,they were shaking..i felt so nervous.i went to a doctor.he adviced me to quit smoking or i can even have heart attack.from that day i started up to quit smoking.i used various resources and links..they helped me a lot in quiting smoking.be healthy,live healthy

Last week, I rented the original The Pink Panther with Peter Sellers. There were several cigarettes in the movie, and it really struck me how much the practice was glamorized. That was in 1963. I was born in 1970, and my childhood had a lot more smokers in it than my adulthood does.

Oddly enough, I seemed to know from the earliest age that smoking was really bad for you. I remember being all of four years old and begging my father to quit. Then, when I went to college to study health information management, part of the curriculum was a two semester course in human anatomy and physiology, complete with cadaver lab. It was there that I saw up close and personally what smoking does to ravage a person's body. Of course, you see it most clearly in the lungs, but other places are seriously affected, too. If I remember right, this specimen was actually riddled with cancer from a primary lung lesion. My wish at the time was that I could have taken pictures to show some of the smokers in my life. Who knows if it would have made the slightest difference, but it just showed me that even as a small child I was onto something about smoking. Of course, I have some bad habits of my own, but none as surely lethal as smoking.

Great idea for a post, Dr. Schwab. Clearly it hits home for many. Like you with the dying lung cancer patient, I'm of two minds with my ailing Mom and this nastiest of habits: give in or Gestapo... Smoking is a lose-lose for those who don't smoke, as well.

I'm 49. I can remember when they made candy cigarettes for kids that looked like scaled-down versions of the real thing, down to the packaging, and how upset my parents were that when I got some at Halloween, they were my favorites. A little borrowed cool factor for a little kid with Mormon parents who didn't smoke like everybody else's did. Uh, yeah, that went over real well at home.

Meantime, thank you for being compassionate towards your patients and seeing things through their eyes. The kindness, even more than the cigarettes themselves, surely meant a lot to them.

Yes, it's remarkable how attitudes change. And in a short period of time.

My father smoked two packs a day for over 40 years and now he is beginning lose the battle against COPD. Amazingly, to him it seems easier to tote an oxygen bottle and avoid stairs than it does to quit smoking. You get used to anything I guess, and sooner or later it just becomes your life.

I am not and have never been a smoker, but I swear I can smell that ashtray in the picture on your original post -- it jerks me right back to being a kid on my father's back porch. I can only imagine the effect the picture would have on him.

You alluded to public awareness of health as a reason for the major change in attitude toward smoking -- you suggest that people my age are much more aware of the issue than people from your parents' generation. That makes sense, but it also raises some pretty interesting questions (or, interesting to me at any rate).

Despite the success with smoking, the public health picture is far from sunshine and flowers. People from my generation make their own poor health choices. I'm thinking specifically of diet and exercise. And maybe lifestyle-mental-health-depression choices, although those relationships are more speculative.

Unlike smokers your parents' age, my peers KNOW how shitty a big mac and video game lifestyle is. But that the effect that knowledge has on decision making seems minimal.

Why do you think that is?

Maybe anti-smoking campaigns work because they catch kids at young ages, warn them, and convince them to be passive and refrain from an activity, where diet/exercise requires a positive effort?

Or because the first big mac tastes better than the first cigarette?

Or maybe they are successful where diet and exercise campaigns fail because human creatures are programmed by evolution to conserve energy and store calories by avoiding excess activity and eating rich foods?

Patrick: those are good questions, to which I don't know the answer. It's true, I think, that smoking is increasing in young girls more than boys; if so, it's really hard to figure, unless it's a perverse form of "you go, girl." When I see kids smoking near their high school or middle school, I always feel like saying something: like, do you know how ugly you'll be in a few years, or, do you know how bad it'll taste to kiss you. I don't say anything, of course.

A few years ago, a patient of mine was hospitalized with recurrent, metastatic throat cancer. He was terribly weak and could barely get back and forth to the bathroom. One evening, he climbed out of bed, shut the door, opened the window, climbed back into bed, and lit up.

Unfortunately in the process, he managed to set his bed on fire. Alarms, fire department, and upheaval followed. The hospital thought about pressing charges but did not. Very memorable.

Some of our patients will never quit. Fortunately, the number of teens smoking continues to drop.Not certain if this link will work, but the percentage of 12th graders that have had a cigarette in the past 30 days has dropped from 36% in 1997 to 22% in 2007. Not perfect, but it is good news.

This one really hit home. I'm 25 and have just quit smoking (as of January) after 10 years of smoking. I come from a full family of smokers - there is not one person in my family who has not smoked regularly at some point in their life.

The effects and consequences of smoking are well known now and the only reason that someone would continue to smoke in light of such knowledge is for three reasons - 1. Fear - of failing, of not having the cigarette to use as a crutch for emotions, of losing your dearest 'friend', of gaining weight and 2. Denial - that you'll be one of the few lucky ones that never gets cancer or lung disease, etc. and 3. Resignation - if you're already sick and dying from lung cancer - what's the point in slowing the inevitable?

I just hope that I didn't smoke enough or long enough or quit with enough time to repair the damage that I've done. It's hard to think about your own mortality in your 20's.

My grandfather died of mesothelioma back in the 80's. He'd been a smoker all of his life. When he was in the hospital about to die he was desperate for another cigarette. He snuck into the closet of his roomate, stole some ill-fitting clothes [he was very tall], and tried to sneak out of the hospital to have a smoke. The nurses caught him and brought him back before he could get out the door.

I always felt terrible that they did that to him, still do. He was going to die anyhow, what would it matter. :(

I used to drink pretty heavily when I was in my early 20's. One night a fellow barfly, a girl I knew, was matching me drink for drink. I took a good look at her, realizing all of a sudden that if I didn't quit - I could look like her. That scared me straight more than anything else. She was slightly over 30 and looked at least 45, with leathery wrinkled skin. Yikes.

Well lisa ,that was funny.I mean atleast for some reason you quit smoking..Still i can help you in a better way...Try this link out,it helped me a lot in stopping smoking--quit smokinggreat work...james

I had to comment on this post, old though it may be... I work as a Cancer Co-ordinator for the NHS. The hospital where I work is supposed to be "smoke free", but every day I come across a patient with cigarette in hand.

It's interesting - I work with the Lung Cancer team, and the lead clinician said to me that he could understand why older people smoked; they gave cigarettes out in the war to boost morale, and the negative side effects weren't widely known. But weget younger patients, smokers who would have been aware of the danger even when they started smoking. To his mind, there was no excuse for them.

I've never smoked. I have a vague intellectual curiosity about why people smoke, but not enough to light up myself - a particularly nasty bout of pneumonia as a child ensured that.

Having said that, our friendly neighbourhood oncologist, on the suject of terminal lung cancer, is of the opinion that the patient may as well enjoy the vice whilst living out their days.

I guess my philosophy is more complex - smoke if smoke you must, in spite of the health hazards, but do it well away from me and mine. Selfish? Maybe. But in a free choice culture if people want to play Russian roulette with their lives they have the right to. But they don't have the right to do so with mine, which is why I get so angry with people who smoke on hospital grounds.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.